Drugs Are Up and Talk Is Down for Depressed Teens

Action Points

Be aware that off-label use of selective serotonin reuptake inhibitors appears to be increasing among children and adolescents being treated for depression. Currently, the FDA has only approved Prozac (fluoxetine) for patients under age 18.

Consider including psychotherapy and mental health counseling when treating adolescent patients with depression. This study indicates that psychotherapy and mental health counseling has declined among child and adolescent patients, yet pharmacotherapy among this group has increased.

STANFORD, Calif., Nov. 16 - The number of adolescents taking antidepressants is up while, at the same time, fewer depressed teens are being treated with psychotherapy or mental-health counseling, researchers here reported.

Antidepressants prescribed to seven-to 17-year-old patients rose from 47% in 1995-1996 to 52% in 2001-2002, including increases in the off-label use of selective serotonin reuptake inhibitors (SSRIs), Stanford researchers reported in the December issue of Journal of Adolescent Health.

Prozac (fluoxetine) is the only SSRI approved by the FDA for patients under age 18.

The number of clinician visits by children and adolescents being seen for depression more than doubled. However, mental-health counseling including psychotherapy dropped from 83% to 68%, the investigators added. Their analysis also showed that between 42% and 52% of all adolescent patient visits involving medication did not include counseling.

"The mirroring pattern of these two types of treatments across time suggests that pharmacotherapy is used to substitute, rather than complement, psychotherapy/mental health counseling," wrote Jun Ma, M.D., Ph.D., and colleagues.

Dr. Ma and his team analyzed data from 1995 through 2002 collected from two surveys, the National Ambulatory Medical Care Survey, and the Outpatient Department, a component of the National Hospital Ambulatory Medical Care Survey.

Over that period, the number of visits by seven-to 17-year-olds in which depression was reported jumped from 1.44 million in 1995-1996 to 3.22 million in 2001-2002.

Among these visits, the number of major depressive disorders diagnosed rose only modestly from 392,160 visits in 1995 to 649,969 visits in 2002.

Yet the number of visits with a depression diagnosis that was not specified increased significantly by 138%, from 693,084 visits in 1995 to 1.64 million visits in 2002. Depression visits were most common among 15-to 17-year-old girls and non-Hispanic Caucasians. The authors said the overall increase in adolescent patients is likely due to the growing awareness of depression in children, a problem that's been historically under-diagnosed.

Even though the rate of major depressive disorders only increased slightly, antidepressant use increased remarkably. SSRIs were the most widely used drugs, accounting for 76% of antidepressants prescribed to adolescent patient population in 1995-1996 and 81% in 2001-2002. Overall, there was a 2.6-fold increase in SSRIs use from 1995-2002, the researchers reported.

Prozac use jumped 100% over this eight-year period; it was prescribed in 207.914 visits in 1995 and in 415,580 visits in 2002.

Paxil (paroxetine) is not FDA-approved for children, but its use jumped 269% over the study period from being reported in 75,781 visits to 279,275 visits.

Zoloft (sertraline), also not FDA-approved for children, was also prescribed more often by the end of the study period. A total of 214,105 visits reported Zoloft use in 1995 compared with 345,576 visits in 2002, a 62% increase, the investigators reported.

"The observation of the increasingly prevalent off-label use of SSRIs, as well as possibly inappropriate use of medications in substitution of psychotherapy/mental health counseling as first-line therapy, raises concerns about physicians' adherence to evidence-based medicine," Dr. Ma and his team wrote.

As drug use increased, counseling decreased. The prevalence of psychotherapy remained above 80% from 1995 to 1998, but then it dropped significantly to 54% in 1999-2000 before rising at 68% at the end of the study period.

When looking at physician specialties, the authors found psychologists were three times more likely to prescribe medication alone (odds ratios, 3.42; 99% confidence interval: 1.26-9.28). Psychologists were almost six times more likely to prescribe medication in combination with counseling (OR 5.87; 99% CI: 1.52-22.59).

Counseling was also twice as common among girls than among boys (OR 2.06; 99% CI: 1.03-4.13). It's unclear why more girls received counseling than boys.

Clinical guidelines from the American Academy of Child and Adolescent Psychiatry recommend that psychotherapy "be used for all children and adolescents whereas antidepressants, preferably in combination with psychotherapy/mental health counseling, be prescribed only to those with severe, psychotherapy-resistant symptoms," the authors added.

The findings come amidst the growing concern over antidepressant use in children and the associated increased risk for suicide. Depression affects up to 8% of children and adolescents in the United States and is a major risk factor for suicide, the third-leading cause of death among teens.

The researchers did not say why physicians are turning away from counseling and are relying more on medication even for patients who do not have major depression. It's possible, the authors said, that prescribing patterns have changed since the FDA's October 2004 decision to require antidepressant manufacturers to include black box warnings on their labels. Recently, the American Psychiatric Association reported that antidepressant use among patients under age 18 dropped by almost 20% after the FDA decision.

"We will be interested in assessing whether decreases in prescriptions have occurred selectively," Dr. Ma said, "that is, among patients where the indications for use are less clear, or whether physicians also have begun to withhold antidepressants in situations where the need is more definite."

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